chlorhexidine use experience: program and policy implications in sub-saharan africa
TRANSCRIPT
Chlorhexidine Use Experience: Program and Policy Implications in Sub-Saharan
Africa
Olayinka Umar-Farouk, MD, MBA
Nosa Orobaton, MD, DrPH, MBA
Uganda’s Maternal and Newborn Health Conference
June 16, 2015
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Objective
• Share programmatic experience and lessons
learned on use of 7.1% Chlorhexidine digluconate
(CHX) for umbilical cord care in Sub-Saharan Africa
with an emphasis on Sokoto State in Nigeria.
See page 67 to 81 at www.slidedocs.com
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Why use Chlorhexidine for cord care?
• Prevents sepsis
• Common portal of entry
• Harmful current cord practices
• CHX application history
• Evidence-based intervention
• User-friendly
• WHO recommended
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Evidence-based Approach Sarlahi District, Nepal: 2002-20061
• 34% lower mortality among neonates if initiated
within 24 hours (single application of CHX)
Sylhet District, Bangladesh: 2007-20092
• 20% lower mortality among neonates (single
application of CHX)
Sindh Province, Pakistan: 2008-20093
• 38% lower mortality among neonates (daily
application for one week)
1. Mullany et al, Lancet 2006
2. Arifeen et al, Lancet 2012
3. Soofi et al, Lancet 2012
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WHO Recommendation on Cord Care
“Daily chlorhexidine (7.1% chlorhexidine digluconate aqueous solution or
gel, delivering 4% chlorhexidine) application to the umbilical cord stump
during the first week of life is recommended for newborns who are born at
home in settings with high neonatal mortality (30 or more neonatal
deaths per 1,000 live births).
Clean, dry cord care is recommended for newborns born in health
facilities and at home in low neonatal mortality settings. Use of
chlorhexidine in these situations may be considered only to replace
application of a harmful traditional substance, such as cow dung, to the
cord stump.”
WHO 2014
Glance at African
countries that have
introduced CHX into
the health system and
their current status of
implementation
Overview of Country and CHX
Indicators
7 Global CHX Working Group 2015
Chlorhexidine Across Sub-Saharan Africa
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Ethiopia
1. CIA World Factbook 2014 estimation
2. UNICEF 2012
Population: 96,633,4581
Neonatal Mortality Rate: 29 neonatal deaths
per 1,000 live births2
9.9%,
89.7%
Facility
Births
Home
Births
Current Status: Introduction
Year of Introduction: 2014
Regimen: Multiple-day
Dosage Formulation: Gel
Chlorhexidine Data:
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Liberia
1. CIA World Factbook 2014 estimation
2. DHS 2013
Population: 4,092,3101
Neonatal Mortality Rate: 26 neonatal deaths
per 1,000 live births2
Current Status: Introduction
Year of Introduction: 2014
Regimen: Multiple-day
Dosage Formulation: Gel
Chlorhexidine Data:
36.9%
61%
Facility
Births
Home
Births
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Democratic Republic of Congo
1. CIA World Factbook 2014 estimation
2. DHS 2013-2014
Population: 77,433,7441
Neonatal Mortality Rate: 28 neonatal deaths
per 1,000 live births2
Current Status: Scale Up
Year of Introduction: 2014
Regimen: Multiple-day
Dosage Formulation: Liquid & Gel
Chlorhexidine Data:
74.9%
22.6% Facility
Births
Home
Births
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Madagascar
1. CIA World Factbook 2014 estimation
2. UNICEF 2012
Population: 23,201,9261
Neonatal Mortality Rate: 22 neonatal deaths
per 1,000 live births2
Current Status: Scale Up
Year of Introduction: 2013
Regimen: Single-day
Dosage Formulation: Gel
Chlorhexidine Data:
35.5%
64%
Facility
Births
Home
Births
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Malawi
1. CIA World Factbook 2014 estimation
2. UNICEF 2012
Population: 17,377,4681
Neonatal Mortality Rate: 24.2 neonatal deaths
per 1,000 live births2
Current Status: Scale Up
Year of Introduction: 2014
Regimen: Single-day
Dosage Formulation: Gel
Chlorhexidine Data:
73.4%
24.3% Facility
Births
Home
Births
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Nigeria
1. CIA World Factbook 2014 estimation
2. DHS 2013
Population: 177,155,7541
Neonatal Mortality Rate: 37 neonatal deaths
per 1,000 live births2
Current Status: Scale Up
Year of Introduction: 2013
Regimen: Multiple-day
Dosage Formulation: Gel
Chlorhexidine Data:
35%
63.1%
Facility
Births
Home
Births
Program experiences
and results from Sokoto
State in Nigeria
Nigeria
Lessons
Learned
and Results
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Sokoto State
Woman in labor at home in Sokoto, Nigeria
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Program Approach in Sokoto, Nigeria
Input Process Outcome
CHLORHEXIDINE
& MISOPROSTOL
SUPPLY BY STATE
GOVERNMENT
HEALTH
FACILITIES
COMMUNITY
HEALTH
VOLUNTEERS
COMMUNITY
HEALTH
RESOURCES &
COMMUNITY
OWNERSHIP
WARD
DEVELOPMENT
COMMITTEES
COMMUNITY
DRUG KEEPERS
MOTHER
NEWBORN
DYAD
INCREASE MATERNAL
SURVIVAL
INCREASE
NEWBORN SURVIVAL
DECREASE
MATERNAL &
NEONATAL
MORBIDITY
Procurement Trainings Distribution Impact Measurement
Distribution Supervision Outcome Tracking Policy Decision
Review Meetings Analysis
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Results Chlorhexidine distribution is twinned with
Misoprostol for preventing postpartum
hemorrhage
About 100-150 women
and newborns access the
commodities daily
87,423 newborns have
received CHX gel and
87,389 mothers have
received misoprostol
3,800 volunteers
and health workers
have been trained
on CHX
application and
administering
misoprostol
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Results
• Community
ownership,
engagement, and
empowerment
• 31 out of 37
states have visited
Sokoto state for a
learning visit
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Results
• Public private partnership
• Stimulus for local production
• Accelerated government commitment
• Review of policy documents, training manuals, drug list
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Policy Guidelines
• Clear national leadership and commitment
• Integration of health program
• Community based approach
• Involvement of all stakeholders from the
beginning
• Public private partnership
• Leverage resources from other country
programs
• Ensure funding commitments
• Define supply strategy
• Identify metrics
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Lessons: Demand Side • Broad-based advocacy is key: religious, traditional, professionals, multi-media
• Community-based distribution key to reach last mile
• Bridge information arbitrage
• Proactive, comprehensive forecasting to prevent shortages
• Promote use of best practices
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Lessons: Demand Side
• Proactive, responsive National
Drug Regulatory Agency
• Integrated community-to-
manufacturer-buyer learning
platform
• Effective distribution channel
• Multiple approach to creating
awareness
• Integrate into delivery kits
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JSI’s model for CHX scale up
Approaches that consider local context and engage local stakeholders are likely to be successful. In every context, regardless of the number of challenges being faced, there is always a way to promote quality MNH care, but the solution should be generated by and with local stakeholders.
Response #15 from SCUS-MHTF Survey 2014
Olayinka Omar-Farouk
Nosa Orobaton
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